The Acutely Unwell Surgical Patient

Airway

• A compromised airway is the most time critical problem, with any small reduction in airway radius significantly affecting air flow
  • Remember that halving airway radius leads to a 16 fold increase in resistance (Poiseuille’s law)
• Examining the oropharynx will afford the opportunity to suction liquid material, which may otherwise descend into the airway lungs and exacerbate existing problems
• Use of the ‘jaw thrust’ to protrude the jaw and open the airway is more appropriate for these patients in whom a simple manoeuvre is required
• Airway adjuncts should be used as and when necessary
  • Nasopharyngeal airways are a useful place to start, as they are relatively well tolerated and can be placed in patients that are biting down, such as those during a seizure
  • Oropharyngeal airways are only tolerated well in patients who are obtunded and no longer have a functional gag reflex
  • Supraglottic airway devices are relatively simple to insert with training and can provide more reliable, temporary support in the patient with airway compromise

Breathing

• Oxygen therapy: Put on 15 litres per minute via a non-rebreathe mask if in any doubt and titrate down oxygen levels from there
  • Do not be tempted to leave a patient in a hypoxic state, prior to oxygen, in order to get an arterial blood gas on air
• An arterial blood gas (ABG) sample is key to appreciating the clinical state and subsequent efficacy of treatment in patients with respiratory compromise
  • It is worth being aware of the risks of hypercapnia in patients with COPD but these patients are a subcohort of COPD patients and oxygenation must be prioritised in the immediate phase
• A plain film chest radiograph (CXR) may be essential in your initial diagnosis for a patient
  • If you feel you patient may be too unwell to be transferred to the X- ray department, then ask for a portable radiograph
• Any wheeze can be treated with nebulised salbutamol 5mg and ipratropium 500micrograms, back to back if needed.
  • Remember that wheeze can also be caused by fluid overload (“cardiac wheeze”), so consider the patient’s fluid status as well
• Treat any suspected infection post-cultures being taken, yet you should not delay administration if any significant delay to cultures is anticipated.

If you think your patient is not breathing effectively or at all but still has a pulse, then this is a respiratory arrest and immediate help in the form of a cardiac arrest team should be sought while you and a colleague use a bag-valve-mask to oxygenate the patient.

Circulation

Shock means that organs are hypoperfused and that means they will begin to fail without aggressive intervention. It is likely that hypovolaemia and sepsis will be responsible for the majority of the shock you deal with as an inpatient, but do remember that other types of shock are possible (the management for sepsis, hypovolaemia, and anaphylaxis can be found elsewhere on the site)

• If the patient is deteriorating, ensure early IV access and insert a wide bore cannula (ideally a grey or orange) to allow for prompt fluid resuscitation
• Start fluid replacement in an attempt to increase the intravascular volume, to increase the blood pressure, and the perfusion of the organs but the constituents of the fluid are important.
  • Try to give the same fluid that you are losing (i.e. give blood products in haemorrhage)

*Be careful not to run through bags with added potassium chloride ‘stat’, as rapid boluses of potassium can cause cardiac arrest.

• Any sick patient should have concurrent blood samples taken for full blood count, urea and electrolytes, coagulation, liver biomarkers, troponin, venous gas samples (for lactate), and blood cultures (if required), as well as a 12 lead ECG to explore whether the shock is of cardiac origin

If you suspect post-operative complications, including internal haemorrhage which would not be amenable to simple compression, then you need to notify your team urgently for further assessment and potentially returning to theatre to explore and manage. Blood (rather than just serosanguinous fluid) in drains, disproportionate pain, and signs of peritonism can all be clues to support any suspected pathology.

Disability

• There is a wide variety of potential pupil changes that can occur, yet typical changes may include:
  • ‘Pinpoint’ or bilaterally constricted pupils (miosis) may indicate opioid toxicity
  • Anisocoria (a unilaterally dilated (mydriasis) pupil) can occur with rising intracranial pressure (including from intracranial haemorrhage), affecting CN III
• Any significant changes in input and output of fluids can alter the blood’s electrolyte content, most commonly hyponatraemia
• Check the blood glucose levels and manage accordingly (results may be transient so careful monitoring is required)
  • Concentrated glucose solutions include buccal agents or oral drinks, intravenous preparations (ranging from 5 to 50% glucose), or IM glucagon
• Any opioid induced respiratory depression, bradypnoea, or coma will require naloxone reversal (results may be transient so careful monitoring is required)
• Any seizures require treatment with benzodiazepines.
  • 10-20mg PR diazepam is typically advised as first line, before 4mg IV lorazepam as second line. If IV is not an option, then 10mg buccal midazolam should be trialled

Exposure

Ensure to check each area of the patient’s body, if no obvious cause of deterioration has been identified previously. This includes, but not limited to, a neurological examination, an abdominal examination, and examination of the upper and lower limbs.